PACE Compliance Manager

Position Summary

This position is responsible for ensuring overall CMS and HFS regulatory compliance while developing, implementing, organizing, and monitoring the Compliance Plan and the Quality Assurance and Performance Improvement Plan (QAPI) for LCHC PACE. This position will coordinate visible, transparent communication with the PACE Medical Director, Chief Operating Officer, External Relations Director, Clinical Services Director and others as requested. In addition, the Manager ensures that data is collected from appropriate sources, is examined, and results are shared with all stakeholders. The Manager is also responsible for procuring, negotiating, executing and monitoring of the PACE contract providers. Promotes professional working relationships with both internal and external customers.

Principal Duties and Responsibilities*

Compliance Oversight

• Responsible for administration of the Compliance Program and QAPI within LCHC PACE. This includes compliance with all state and federal program requirements, obtaining and maintaining certification under CMS, and any other state or federal laws.
• Develop and maintain a working knowledge of applicable Federal, State, and local laws and regulations, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
• Promote and maintain collaborative relationships with managers, peers, and customers by effectively fostering a team environment, building consensus and resolving conflicts.
• In conjunction with External Relations Director and Medical Director, initiates, develops, and guides the implementation of the annual Compliance Plan and Quality Assurance Performance Improvement Plan. Compiles quarterly and annual reports to present to the Compliance Officer, LCHC PACE leadership, staff, contractors, administration, the Participant Advisory Committee (PAC), and Board of Directors in accordance with the Compliance Plan and the QAPI.
• Schedule and assist in facilitating the PACE Compliance Committee in collaboration with the Medical Director, the Compliance Officer, and the Business Development Director. Duties include preparation of meeting agenda, preparation of minutes, and assistance with committee correspondence and presentation materials.
• Communicate Compliance and QAPI plan as needed to members, staff, contractors, administration, Participant Advisory Committee (PAC) and Board of Directors.
• Ensure compliance with CMS regulations. Responsible for the Medicare Part D fraud, waste and abuse Compliance Program. Conduct annual review and approval of Compliance Program. Ensure that colleagues complete all requirements identified in the Compliance program and those related to the HIPAA privacy rule.
• Prepare for CMS sites visits, inspections, and all subsequent follow up activities.
• Analyze risk management data and QI data in order to identify and control loss.
• Coordinate and maintain all activities pertaining to investigation and response to complaints, service delivery requests, and grievances/appeals, assures regulatory compliance and incident reporting including trend analysis for necessary action plans and quality improvement initiatives.
• Ensure accurate and timely reporting to CMS, State, and all other PACE reporting requirements.
• Daily monitoring of HPMS complaints and memorandums for quality and compliance updates. Coordinate any necessary actions per HPMS memorandum guidance.

Contract Oversight

• Develops contractual relationships with service providers, such as negotiating rates and draft contract agreements. Negotiates effective contracts with both professional and institutional vendors on behalf of the PACE organization, and amends contracts, as needed.
• Meets with Contracted Community Providers (CCPs) for Periodic Observation and Review per CMS regulation timeframes and conducts follow up, if Corrective Action Plan is warranted.
• Responsible for new contractor initial provider orientation training for all contracted providers to ensure contract compliance and adequate education of the contractor.
• Responsible for establishing and maintaining complete Contracted Community Provider (CCPs) files and ensuring compliance and accuracy, including complete monthly OIG and EPLS documented checks and follow up.
• Conducts Provider Survey every two years, with results presented to Medical Director and Chief Operating Officer with recommendations based on any trends. Follow up with the IDT and contract providers on any issues that need to be addressed as a result of the survey.
• Develops provider network to meet PACE participant needs.
• Responsible for tracking appeals from initiation to completion based on CMS guidelines prescribed in PACE regulations. Ensures a rigorous internal review is completed, with any external reviews by independent third party reviewers coordinated by the Contract Liaison, if applicable. Responsible for documentation related to appeals made by PACE participants.
• Follows all Policies, Standard Operating Procedures and OSHA safety guidelines.
• Other duties as requested/assigned.

Required Skills or Abilities*

1. Ability to strongly embrace and personify the mission of the Lawndale Christian Health Center.
2. Strong administrative and project management skills.
3. Excellent communication skills both oral and written.
4. Quantitative skills required to work with spreadsheets and produce reports.
5. Ability to organize, prioritize, multi-task, manage deadlines, and work independently.
6. Requires experience and/or demonstrated abilities for working in a multi-cultural, fast-paced setting.
7. Proven ability to complete projects according to outlined scope, budget, and timeline
8. Ability to collaborate and interact with a diverse group of health care professionals.

Required Knowledge, Experience, or Licensure/Registration

1. A bachelor's degree and 2 plus years of administrative experience.
2. Experience negotiating and executing contracts preferred.
3. Must have a current Illinois Driver’s License and driving record must be in compliance with Company policy. Must maintain current automobile insurance. You will be required to drive your own car for company business. PACE reimburses for mileage.